ElderGrade

Inspection citations at Three Creeks Post Acute

43 citations on record, 2 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 15 0
2025 6 1
2024 13 1
2023 9 0
D March 3, 2026 Tag F0801 Corrected May 2026

Nutrition and Dietary Deficiencies

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

No actual harm, potential for more than minimal harm

D March 3, 2026 Tag F0755 Corrected May 2026

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D March 3, 2026 Tag F0699 Corrected May 2026

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

No actual harm, potential for more than minimal harm

D March 3, 2026 Tag F0686 Corrected May 2026

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D March 3, 2026 Tag F0684 Corrected May 2026

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D March 3, 2026 Tag F0657 Corrected May 2026

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D March 3, 2026 Tag F0584 Corrected May 2026

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, potential for more than minimal harm

D March 3, 2026 Tag F0582 Corrected May 2026

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

No actual harm, potential for more than minimal harm

E March 3, 2026 Tag F0921 Corrected May 2026

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

No actual harm, potential for more than minimal harm

E March 3, 2026 Tag F0887 Corrected May 2026

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

No actual harm, potential for more than minimal harm

E March 3, 2026 Tag F0812 Corrected May 2026

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E March 3, 2026 Tag F0760 Corrected May 2026

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

No actual harm, potential for more than minimal harm

E March 3, 2026 Tag F0689 Corrected May 2026

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

E March 3, 2026 Tag F0645 Complaint investigation Corrected May 2026

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

No actual harm, potential for more than minimal harm

D February 26, 2026 Tag F0740 Complaint investigation Corrected Mar 2026

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

No actual harm, potential for more than minimal harm

C December 22, 2025 Tag F0584 Complaint investigation Corrected Jan 2026

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, minimal potential

D December 22, 2025 Tag F0644 Complaint investigation Corrected Jan 2026

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

No actual harm, potential for more than minimal harm

L December 22, 2025 Tag F0812 Complaint investigation Corrected Jan 2026

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Immediate jeopardy to resident health or safety

D November 10, 2025 Tag F0760 Complaint investigation Corrected Feb 2026

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

No actual harm, potential for more than minimal harm

D November 10, 2025 Tag F0600 Complaint investigation Corrected Dec 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, potential for more than minimal harm

E January 10, 2025 Tag F0880 Complaint investigation Infection control Corrected Feb 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D November 17, 2024 Tag F0801 Corrected Dec 2024

Nutrition and Dietary Deficiencies

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

No actual harm, potential for more than minimal harm

D November 17, 2024 Tag F0695 Corrected Dec 2024

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D November 17, 2024 Tag F0625 Corrected Dec 2024

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

No actual harm, potential for more than minimal harm

D November 17, 2024 Tag F0622 Corrected Dec 2024

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

No actual harm, potential for more than minimal harm

D November 17, 2024 Tag F0582 Corrected Dec 2024

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

No actual harm, potential for more than minimal harm

D November 17, 2024 Tag F0578 Corrected Dec 2024

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

No actual harm, potential for more than minimal harm

E November 17, 2024 Tag F0812 Corrected Dec 2024

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

D May 24, 2024 Tag F0610 Complaint investigation Corrected Jun 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

D May 24, 2024 Tag F0609 Complaint investigation Corrected Jun 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D May 24, 2024 Tag F0580 Complaint investigation Corrected Jun 2024

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, potential for more than minimal harm

G May 24, 2024 Tag F0684 Complaint investigation Corrected Jun 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Actual harm to a resident

D May 1, 2024 Tag F0804 Complaint investigation Corrected Jun 2024

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

E May 1, 2024 Tag F0725 Complaint investigation Corrected Jun 2024

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

No actual harm, potential for more than minimal harm

D December 5, 2023 Tag F0677 Complaint investigation Corrected Dec 2023

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

D December 5, 2023 Tag F0609 Complaint investigation Corrected Dec 2023

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

F November 9, 2023 Tag F0880 Complaint investigation Infection control Corrected Dec 2023

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D October 2, 2023 Tag F0624 Complaint investigation Corrected Oct 2023

Resident Rights Deficiencies

Prepare residents for a safe transfer or discharge from the nursing home.

No actual harm, potential for more than minimal harm

D August 19, 2023 Tag F0698 Corrected Sep 2023

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

No actual harm, potential for more than minimal harm

E August 19, 2023 Tag F0812 Corrected Sep 2023

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.